Analysis Radio Communications The transmissions by the GennyandDoug from within St.John's Harbour would likely not have been heard by the OOW of the CCGS SirWilfredGrenfell, and the response by MCTS provided listeners with limited information pertaining to the departure of the fishing vessel. The OOW of the CCGS SirWilfredGrenfell was aware of MCTS procedures and initiated the call-in immediately following that of the fishing vessel. The OOW ought to have been aware that the GennyandDoug was departing the berth in St.John's Harbour. However, no attempt was made by the OOW of the CCGS SirWilfredGrenfell to contact the vessel to ascertain its position, confirm its intentions, and/or to arrange a safe passage. The OOW of the GennyandDoug meant to call the CCGS SirWilfredGrenfell at 0115, but mistook the name as the SirWilfredTempleman. Although St.John's MCTS corrected the GennyandDoug, no follow-up calls were made until two minutes before the collision. Although the OOWs of the two vessels knew that a potential converging situation existed, neither vessel made its intentions known to the other in a timely manner to arrange a safe passage, nor did they take appropriate measures in ample time to avoid collision. Bridge Operating Practices and Procedures Effective Use of Navigational Equipment The OOW of the CCGS SirWilfredGrenfell was primarily monitoring the starboard (X-band) radar during the time leading up to the collision. Despite manipulating radar controls, the OOW was unable to pick up the fishing vessel on the radar until both vessels were about one-half mile apart. However, a post-occurrence technician's report showed the radar to be in good working order. No defects or deficiencies in the radar had been reported by the ship's personnel prior to the collision. Considering the light winds, low sea state and limited precipitation in the form of fog, the fact that the OOW did not pick the GennyandDoug up on the radar screen suggests that either the radar was not adjusted for optimum performance, or that it was not monitored closely. The port (S-band) radar was not being used. The problems associated with poor target response from this radar were known to have existed, off and on, for a long period of time. Consequently, information obtained from the radar could not be relied upon. This effectively negated its use, especially in poor-visibility conditions. The OOW of the GennyandDoug was monitoring one of the vessel's two radars and had picked up the CCGS SirWilfredGrenfell after clearing the entrance to the harbour. From the information available, he was able to determine that a close-quarters situation existed with the CCGS SirWilfredGrenfell and attempted to alleviate this by means of a call on the VHFand an alteration to starboard of about 40about two minutes prior to the collision. Conduct of Navigation The two vessels were steering near reciprocal courses in a near head-on situation when the GennyandDoug cleared the Narrows. The OOW of the CCGS SirWilfredGrenfell should have been aware of the presence of the fishing vessel from the time the fishing vessel departed from the wharf, some 22minutes prior to the collision. However, the fishing vessel was not picked up on the radar screen until the vessels were about one-half mile apart- a steaming time of less than two minutes. Given that the CCGS SirWilfredGrenfell was operating in visibility of about one-half mile, the OOWought to have established VHFcontact and reduced his speed in accordance with good seamanship practices. On the other hand, the fishing vessel was monitoring the progress of the CCGS SirWilfredGrenfell and did not give it a wide berth at an early stage. This situation indicates that both vessels failed to take reasonable measures to ensure safe navigation, consistent with the environment in which they were operating. Bridge Crewing in Restricted Visibility Consistent with good seamanship practices and Bridge Standing Orders, the CCGS SirWilfredGrenfell commanding officer was notified when the vessel encountered restricted visibility and again when the vessel was cleared to return to port. During the commanding officer's last visit to the bridge prior to the collision, he communicated briefly with the OOWand then proceeded below deck. The OOW was left in charge of the bridge until the commanding officer's return following the collision. This situation occurred despite the fact that the OOWhad limited experience being in charge of a navigation watch or operating a vessel in restricted visibility. Furthermore, the vessel was operating in proximity to land and the harbour entrance. This situation presented risks that might have been mitigated by the commanding officer's presence on the bridge at a critical phase of the voyage. The captain of the GennyandDoug remained on the bridge from the time of departure from the dock until the time of the collision, with the exception of a two-minute interval when he went below decks to assign watches to the crew. At the time of collision, the OOW and a watchman were also present in the wheelhouse. Implementation of BRM Although the safety management system on the SirWilfredGrenfell embraced the BRM philosophy, it was not fully implemented. To do so would have required the bridge to be crewed by an experienced officer and the navigation team to be composed of personnel who could share the workload. This would not have placed the OOWin the precarious situation of working in isolation without the synergy of the team. Furthermore, it would have provided an opportunity for discussion of the vessel's speed, traffic in the vicinity, and the sharing of workload, including monitoring the execution of the helm orders- all of which would have provided an opportunity to mitigate the risks at this safety-critical phase of the voyage. As is the case with most fishing vessels, the GennyandDoug, having only the captain and the mate, had neither a formal safety management system or BRM in place. However, the captain, the OOW and a watchman were on the bridge sharing the workload and working as a team. Coast Guard Procedures and Practices The CCGS SirWilfredGrenfell's International Safety Management checklist for navigating in restricted visibility was entered in the log as completed by the chief mate before midnight, in accordance with coast guard directives. Before handing over the watch, the chief mate related to the second mate that the master had been made aware of the restricted visibility, the fog signal was sounding and they had discussed the known traffic in the area. The checklists are intended as aide mmoires to help ensure that all elements essential to the task, in accordance with established procedures and practices, have been considered, thereby augmenting safety. The navigation in restricted visibility checklist included the following: Proceed at a safe speed appropriate to the circumstances The speed of the CCGS SirWilfredGrenfell was determined to be 15 knots right up until two minutes before the collision. The OOW of the CCGS SirWilfredGrenfell did not begin to slow the vessel down until after he was contacted by the GennyandDoug for the first time. At this stage, the vessels were one-half mile apart, some two minutes before the collision. Navigating a vessel in the proximity of the harbour entrance at 15 knots in restricted visibility under the circumstances noted cannot be considered a safe speed. Maintain a careful radar watch, check for optimal performance and detection Optimal performance of the radar can only be determined by reviewing the information on the radar screen in relation to the objects in the area. The presence of the fishing vessel ought to have been known, but it was not picked up on the radar screen. Maintain a careful radio watch, and broadcast Security call, if necessary Given that the vessel was operating in fog at the entrance to the harbour and that the radar performance was less than optimal, the broadcast on VHF 16 of a security message would have alerted vessels in the area to its position. However this was not done. Implementing the established procedures as set forth in the checklists would have helped to mitigate the risks. Procedures and Practices on the GennyandDoug The personnel in the wheelhouse of the GennyandDoug at the time of the collision consisted of the captain, the mate and a seaman acting as lookout. When the mate took over the conduct from the captain after leaving the dock, the captain ensured that the mate left the steering in manual control until clearing the harbour entrance, which was his practice. The captain instructed the mate to call the CCGS SirWilfredGrenfell after passing Fort Amherst and ensured that he had done so again just prior to the collision. The two officers felt that it should have been a normal port-to-port passing, albeit a close one, given the GennyandDoug's late alteration of course to starboard and the CCGS SirWilfredGrenfell's failure to alter course to starboard. The GennyandDoug was travelling at 6knots and was maintaining a radar watch, having picked up the CCGS SirWilfredGrenfell at Fort Amherst. The GennyandDoug's OOW made an unsuccessful attempt to contact the CCGS SirWilfredGrenfell by radio, but a prompt follow-up call to the CCGS SirWilfredGrenfell was not made following an intervention by theMCTS. Furthermore, GennyandDoug did not broadcast a security call on VHF16. Helm Orders When the OOW of the CCGS SirWilfredGrenfell became aware that a close-quarters situation was inevitable, the two vessels had already converged to within one-half mile of one another. At this critical juncture, he ordered the helmsman to alter course to starboard without indicating which course to steer or how many degrees of starboard helm to apply. Internationally accepted procedures for issuing helm and steering orders include either giving the helmsman a course to steer or the exact angle of rudder sought. As the helm order was ambiguous, the helm execution was limited to five and ten degrees of starboard helm. When the OOW did not get the desired result of the vessel turning to starboard and given that the fishing vessel was nearby, he queried the helmsman as to whether the helm was to port. Some confusion ensued as to what helm order was requested and the helmsman applied port rudder, thereby turning the vessel to port. Furthermore, the helmsman did not repeat the OOW's order. The standard practice of repeating the orders is intended to ensure that helm orders are clearly understood, thereby reducing the chances of error. The necessity of doing so is stressed in the STCW95 Bridge Watchman Training Course (TP10936E)8 syllabus. Using the standard practice to give helm orders and closely monitoring their execution would have helped to mitigate the risk of a wrong execution of the helm at a critical time in the vessel's passage. Furthermore, it would have provided the OOWwith an opportunity to recognize the error at an early stage and allow for remedial measures. As is typical on fishing vessels, most of the electronics and navigation tools on the GennyandDoug were centred around the console. As most fishing vessels are designed to be navigated by a single officer, the controls are usually within easy reach of theOOW. The OOWon the GennyandDoug was navigating the vessel stationed at the console. The GennyandDoug was steering under manual control until it reached Fort Amherst, where the OOWswitched over to autopilot. The vessel was still on autopilot at the time of collision. While operating in reduced visibility, neither crew took appropriate measures in ample time to avoid collision. On the GennyandDoug no immediate attempt was made to contact the Canadian Coast Guard ship (CCGS) SirWilfredGrenfell following an earlier unsuccessful transmission, nor was a security call made. On the CCGS SirWilfredGrenfell, while operating at or near full speed, standard helm orders were not used and the execution of helm orders was not closely monitored, resulting in the vessel altering course into the path of the GennyandDoug. Bridge Resource Management principles were not fully implemented, resulting in the bridge of the CCGS SirWilfredGrenfell being insufficiently crewed with suitable personnel. The risks associated with operating a vessel in reduced visibility while approaching a port were not fully addressed.Findings as to Causes and Contributing Factors While operating in reduced visibility, neither crew took appropriate measures in ample time to avoid collision. On the GennyandDoug no immediate attempt was made to contact the Canadian Coast Guard ship (CCGS) SirWilfredGrenfell following an earlier unsuccessful transmission, nor was a security call made. On the CCGS SirWilfredGrenfell, while operating at or near full speed, standard helm orders were not used and the execution of helm orders was not closely monitored, resulting in the vessel altering course into the path of the GennyandDoug. Bridge Resource Management principles were not fully implemented, resulting in the bridge of the CCGS SirWilfredGrenfell being insufficiently crewed with suitable personnel. The risks associated with operating a vessel in reduced visibility while approaching a port were not fully addressed. The port radar (S-band) on the CCGS SirWilfredGrenfell was not functioning properly for an extended period of time and was unreliable, thereby depriving the ship's complement of its use.Finding as to Risk The port radar (S-band) on the CCGS SirWilfredGrenfell was not functioning properly for an extended period of time and was unreliable, thereby depriving the ship's complement of its use.